=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659465144
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO FALLETTI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | #62 DR VEVE
-----------------------------------------------------
City | SAN GERMAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-892-3672
-----------------------------------------------------
Fax | 787-892-6909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 124
-----------------------------------------------------
City | SAN GERMAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00683-0124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-892-3672
-----------------------------------------------------
Fax | 787-892-6909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | PR2369
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------